Princess Margaret Cancer Centre Familial Breast and Ovarian Cancer Clinic. Family History Questionnaire

Transcription

1 Princess Margaret Cancer Centre Familial Breast and Ovarian Cancer Clinic Family History Questionnaire How to complete this questionnaire The information in this questionnaire will be used to determine when and if you should be scheduled for an appointment for genetic counselling and/or high risk breast cancer screening. You may find it helpful to contact other family members to get information about more distant relatives. If you do not know much about your family history, do the best you can. Any information is helpful and will allow us to more accurately assess your family history. To fill in the tables: - Complete the tables as shown in the example at the top of the first page. - List all family members, those with and without cancer. - If your family is very large, you may photocopy or add more sheets of paper. - If exact age is not known, give your closest guess of age or age range. - If the person is living, leave column blank. - If the person had passed away, leave column blank. - If the person has never had cancer, leave column and column blank. The tables will ask you for information about your: - immediate family (your spouse, children, brothers and sisters) - nieces and nephews - mother s family - father s family - other family members who may have been diagnosed with cancer If you have questions or need help completing this form, call the Familial Breast and Ovarian Cancer Clinic at ext Consent By signing below, you consent that the family history you provide will be available to other members of your family seen for genetic counselling. This means that other relatives will not have to complete this questionnaire and that other relatives will be able to add their information to the family tree. Name (print): Signature: Date Updated: 2013/01/13 1

2 1. What part of the world did your family originally come from (your ancestry/ethnic background)? Mother s side: Father s side: 2. Is your family Ashkenazi Jewish? t sure 3. Has anyone in your family married a blood relative If yes, please list which relatives and explain how they are related to each other 4. Do any of your children have different fathers? [ ] I do not have children If yes, please indicate in the margin of the tables below, beside each child, the name of his or her father. 5. Are any of your brothers or sisters half-brothers or half-sisters? [ ] I do not have brothers or sisters If yes, please write in the margin of the tables below whether you share the same mother or father Updated: 2013/01/13 2

3 1. Your Immediate Family EXAMPLE SMITH, JANE (JONES) 52 F BREAST 49 EXAMPLE SMITH, MARGARET (JONES) F OLD AGE EXAMPLE JONES, BOB 70 M PROSTATE 60s EXAMPLE SMITH, MARY (JONES) F 50s UNKNOWN You Your Partner Your Children Your Brothers & Sisters Updated: 2013/01/13 3

4 2. Your Nieces and Nephews Their Parent s Name (Your brother or sister) 3. Your Mother s Family Your Mother Mother s Mother (Your Grandmother) Mother s Father (Your Grandfather) Mother s Brothers & Sisters (Your Aunts and Uncles) Updated: 2013/01/13 4

5 4. Children of Your Mother s Brothers and Sisters (Your Maternal First Cousins) Their Parent s Name (your mother s brother or sister) 5. Your Father s Family Your Father Father s Mother (Your Grandmother) Father s Father (Your Grandfather) Your Father s Brothers and Sisters (your Aunts and Uncles) Updated: 2013/01/13 5

6 6. Children of Your Father s Brothers and Sisters (Your Paternal First Cousins) Their Parent s Name (your father s brother or sister) 7. Other Family Members Diagnosed with Cancer (not listed above) MILLER, LISA (STANLEY) Exact Relationship to You MATERNAL GRANDMOTHER S SISTER UTERINE HEART ATTACK Updated: 2013/01/13 6